You are an attending on the inpatient unit of your community psychiatric hospital, and the nursing staff informs you of a new admission. Mary is a 26-year-old single woman with schizophrenia; this is her third psychiatric admission. For the past week, Mary has been feeling more suspicious, and she hasn’t been eating much due to a belief that she is being poisoned. She says, “I’m scared they’re coming to get me because I can hear their inner consciences talking everywhere. My mom made me come, and I don’t need to be here because she thinks I’m crazy. I just haven’t been feeling good.” You go into the nurse’s station, confer with the staff and Mary’s outpatient psychiatrist, and decide to increase the dosage of Mary’s risperidone. The next day on rounds, the nursing staff tells you that Mary declined the risperidone, claiming the pill was the “wrong color,” and that she is requesting to be discharged.
Most of us who have done inpatient work on a locked unit will recognize this fairly common scenario. In the vignette, you are practicing according to the standard of care, in which you and your staff each evaluate a patient, have a discussion in a team meeting, come up with a treatment plan, and implement it. You do your best to align with your patient on a plan, and you see confrontation and struggle as a necessary consequence of providing care for people with psychotic illness who have little insight.
While this standard of care works for some patients, in many cases it leads to involuntary commitments, court hearings, and traumatic experiences such as seclusion and restraint. Medications help decrease the need for such measures, but meds often do not work quickly enough (or at all), and they may cause unacceptable side effects. Plus, patients may disagree with their providers and family members about the need for medication or even the need for treatment, as providers and patients may not be using the same vocabulary to discuss the issues. We have to do better, and one promising approach that may help is called “Open Dialogue.”
Open Dialogue’s genesis
In 2001, the Institute of Medicine (IOM) wrote an influential report that identified a “quality chasm” in health care (across all branches of medicine) and called upon providers to focus on patient-centered care. The IOM defined this approach as being “respectful of and responsive to individual patient preferences, needs, and values” (Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, 2001. http://www.nap.edu/html/quality_chasm/reportbrief.pdf). Since that report, many health care systems have developed initiatives to increase patient and family participation. Psychiatry has been slower than other specialties to adopt these initiatives, in part because we sometimes see patients with serious mental illness as less able to participate in care discussions. However, one can argue that people in the midst of a psychiatric crisis like psychosis are most in need of transparent, open, and collaborative care.
Open Dialogue, developed in the 1990s in Tornio, Finland, is both a way of communicating (while paying attention to one’s vocabulary) and a system of care. All communication about patients occurs in their presence and is based on respectful language that is often derived from the patient’s own words. The Open Dialogue vocabulary refers to the patient as “the person at the center of concern,” and it drops clinical jargon in favor of creating a common language. (For this article, we will still use the term “patient” as we will often see them in a clinical setting.)
Through Open Dialogue, two or more clinicians will hold “network meetings” to rapidly engage a person in crisis, most often in the patient’s home and alongside the patient’s support network or family. For continuity, the clinical team remains the same through outpatient and inpatient care, using a flexible approach of meeting as frequently (or infrequently) as needed. Clinicians carefully evaluate patients to create a shared understanding of the psychosis or crisis, and are somewhat less likely to medicate right away than in many other treatment settings. Instead, they deliberately formulate treatment plans, often delaying medications or using lower doses or shorter-term medications when safe to do so (Seikkula J et al, Psychosis 2011;3(3):192– 204. doi:10.1080/17522439.2011.595819).
Open Dialogue also entails a series of methods for communicating with patients most effectively during treatment meetings. These methods are termed “dialogic practice” and include 12 key elements (Olson M et al, The Key Elements of Dialogic Practice in Open Dialogue. Worcester, University of Massachusetts Medical School, 2014. http://tiny.cc/yhdsiy), which we’ll explore in more detail below.
Is Open Dialogue effective?
Open Dialogue has been tested in a five-year multi-center study in Finnish Western Lapland. 42 people with non-affective psychosis like schizophrenia were enrolled. In this area of Finland, Open Dialogue is the standard system of care for public mental health, and all persons with non-affective psychosis who were being treated using Open Dialogue were eligible to join the study. Outcomes were compared with a retrospective control group of 33 people treated before implementation of Open Dialogue. Compared with the control group, people treated with Open Dialogue experienced more rapid improvement in Brief Psychiatric Rating Scale symptoms of psychosis, though five-year total scores were similar between the groups. After five years, 82% of patients had a full remission of psychotic symptoms, 86% of patients returned to employment or education, and only 17% remained on antipsychotics (Seikkula J et al, Psychother Res 2006;16:214–228).
Although these results were based on a small number of patients, the study was influential because these outcomes were dramatically better than long-term outcomes reported in other studies in which patients received standard treatment. In such studies, after five years, typically only 40% of psychotic patients had remission of symptoms, over 50% were still on disability, and over 90% were still taking antipsychotics (these studies were reviewed in Seikkula et al, 2006). Groups in a number of other European countries have implemented an Open Dialogue model but have yet to report outcome data (Gordon C et al, Psychiatr Serv 2016;67(11):1166–1168).
In the United States, through grant funding, Open Dialogue has been implemented in a 12-month feasibility study of 14 young adults (ages 14–35) with psychosis in an outpatient mental health agency in Massachusetts. This initial study has demonstrated qualitatively high satisfaction for participants, families, and providers. Quantitatively, participants exhibited significant positive changes in symptoms and functional outcomes, as measured by the standard symptom rating scales. Most participants (nine out of 14) were working or in school after one year (Gordon et al, 2016).